Does 42509 require prior authorization?

No, 42509 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 42509?

Medicare facility rate: $718.79. Non-facility rate: $718.79. Work RVU: 11.47.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

11.47

Facility

$718.79

Non-Facility

$718.79

Documented evidence of excessive drooling associated with significant morbidity (examples given: skin maceration, poor oral hygiene, dehydration).
Documentation of failure to adequately respond to appropriate conservative measures, specifically physical therapy and drug therapy (record of therapies tried, duration, responses, adverse effects or reasons for discontinuation).
Documented diagnosis using appropriate ICD-10 codes when selection criteria are met (policy lists K11.1 and K11.7 as covered diagnoses).
Clinical notes and pre-operative evaluation justifying the selection of the specific surgical procedure (including consultations as clinically applicable — e.g., otolaryngology, dentistry, speech therapy) to support that member meets selection criteria.

The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Parotid duct diversion, bilateral, with excision of one submandibular gland.
The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Parotid duct diversion, bilateral, with excision of both submandibular glands.
The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Parotid duct diversion, bilateral, with ligation of both submandibular ducts.
The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Relocation of the submandibular ducts, with or without removal of sublingual glands.
The following surgical procedures to control excessive drooling may be considered medically necessary for members who meet the selection criteria listed above: Tympanic neurectomy or chorda tympani neurectomy.
Covered ICD-10 diagnoses (when selection criteria are met): K11.1 (Hypertrophy of salivary gland).

AETNA-CPB-0265 — Surgical Treatments to Control Drooling (Sialorrhea)

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